1
|
Gouchoe DA, Cui EY, Satija D, Henn MC, Choi K, Rosenheck JP, Nunley DR, Mokadam NA, Ganapathi AM, Whitson BA. Ex Vivo Lung Perfusion and Primary Graft Dysfunction Following Lung Transplantation: A Contemporary United Network for Organ Sharing Database Analysis. J Clin Med 2024; 13:4440. [PMID: 39124711 PMCID: PMC11313603 DOI: 10.3390/jcm13154440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 07/14/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Primary graft dysfunction (PGD) has detrimental effects on recipients following lung transplantation. Here, we determined the contemporary trends of PGD in a national database, factors associated with the development of PGD grade 3 (PGD3) and ex vivo lung perfusion's (EVLP) effect on this harmful postoperative complication. Methods: The United Network for Organ Sharing database was queried from 2015 to 2023, and recipients were stratified into No-PGD, PGD1/2, or PGD3. The groups were analyzed with comparative statistics, and survival was determined with Kaplan-Meier methods. Multivariable Cox regression was used to determine factors associated with increased mortality. PGD3 recipients were then stratified based on EVLP use prior to transplantation, and a 3:1 propensity match was performed to determine outcomes following transplantation. Finally, logistic regression models based on select criteria were used to determine risk factors associated with the development of PGD3 and mortality within 1 year. Results: A total of 21.4% of patients were identified as having PGD3 following lung transplant. Those with PGD3 suffered significantly worse perioperative morbidity, mortality, and had worse long-term survival. PGD3 was also independently associated with increased mortality. Matched EVLP PGD3 recipients had significantly higher use of ECMO postoperatively; however, they did not suffer other significant morbidity or mortality as compared to PGD3 recipients without EVLP use. Importantly, EVLP use prior to transplantation was significantly associated with decreased likelihood of PGD3 development, while having no significant association with early mortality. Conclusions: EVLP is associated with decreased PGD3 development, and further optimization of this technology is necessary to expand the donor pool.
Collapse
Affiliation(s)
- Doug A. Gouchoe
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
- COPPER Laboratory, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Ervin Y. Cui
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
- COPPER Laboratory, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Divyaam Satija
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Matthew C. Henn
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
| | - Kukbin Choi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
| | - Justin P. Rosenheck
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Nahush A. Mokadam
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
| | - Asvin M. Ganapathi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
| | - Bryan A. Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
- COPPER Laboratory, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| |
Collapse
|
2
|
Scaravilli V, Turconi G, Colombo SM, Guzzardella A, Bosone M, Zanella A, Bos L, Grasselli G. Early serum biomarkers to characterise different phenotypes of primary graft dysfunction after lung transplantation: a systematic scoping review. ERJ Open Res 2024; 10:00121-2024. [PMID: 39104958 PMCID: PMC11298996 DOI: 10.1183/23120541.00121-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/12/2024] [Indexed: 08/07/2024] Open
Abstract
Background Lung transplantation (LUTX) is often complicated by primary graft dysfunction (PGD). Plasma biomarkers hold potential for PGD phenotyping and targeted therapy. This scoping review aims to collect the available literature in search of serum biomarkers for PGD phenotyping. Methods Following JBI and PRISMA guidelines, we conducted a systematic review searching MEDLINE, Web of Science, EMBASE and The Cochrane Library for papers reporting the association between serum biomarkers measured within 72 h of reperfusion and PGD, following International Society for Heart and Lung Transplantation (ISHLT) guidelines. We extracted study details, patient demographics, PGD definition and timing, biomarker concentration, and their performance in identifying PGD cases. Results Among the 1050 papers screened, 25 prospective observational studies were included, with only nine conducted in the last decade. These papers included 1793 unique adult patients (1195 double LUTX, median study size 100 (IQR 44-119)). Most (n=21) compared PGD grade 3 to less severe PGD, but only four adhered to 2016 PGD definitions. Enzyme-linked immunosorbent assays and the multiplex bead array technique were utilised in 23 and two papers, respectively. In total, 26 candidate biomarkers were identified, comprising 13 inflammatory, three endothelial activation, three epithelial injury, three cellular damage and two coagulation dysregulation markers. Only five biomarkers (sRAGE, ICAM-1, PAI-1, SP-D, FSTL-1) underwent area under the receiver operating characteristic curve analysis, yielding a median value of 0.58 (0.51-0.78) in 406 patients (276 double LUTX). Conclusions Several biomarkers exhibit promise for future studies aimed at PGD phenotyping after LUTX. To uncover the significant existing knowledge gaps, further international prospective studies incorporating updated diagnostic criteria, modern platforms and advanced statistical approaches are essential.
Collapse
Affiliation(s)
- Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Gloria Turconi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Sebastiano Maria Colombo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Marco Bosone
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lieuwe Bos
- Department of Intensive Care, University of Amsterdam, Amsterdam, Netherlands
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
3
|
Cantu E, Diamond J, Ganjoo N, Nottigham A, Ramon CV, McCurry M, Friskey J, Jin D, Anderson MR, Lisowski J, Le Mahajan A, Localio AR, Gallop R, Hsu J, Christie J, Schaubel DE. Scoring donor lungs for graft failure risk: The Lung Donor Risk Index (LDRI). Am J Transplant 2024; 24:839-849. [PMID: 38266712 DOI: 10.1016/j.ajt.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
Lung transplantation lags behind other solid organ transplants in donor lung utilization due, in part, to uncertainty regarding donor quality. We sought to develop an easy-to-use donor risk metric that, unlike existing metrics, accounts for a rich set of donor factors. Our study population consisted of n = 26 549 adult lung transplant recipients abstracted from the United Network for Organ Sharing Standard Transplant Analysis and Research file. We used Cox regression to model graft failure (GF; earliest of death or retransplant) risk based on donor and transplant factors, adjusting for recipient factors. We then derived and validated a Lung Donor Risk Index (LDRI) and developed a pertinent online application (https://shiny.pmacs.upenn.edu/LDRI_Calculator/). We found 12 donor/transplant factors that were independently predictive of GF: age, race, insulin-dependent diabetes, the difference between donor and recipient height, smoking, cocaine use, cytomegalovirus seropositivity, creatinine, human leukocyte antigen (HLA) mismatch, ischemia time, and donation after circulatory death. Validation showed the LDRI to have GF risk discrimination that was reasonable (C = 0.61) and higher than any of its predecessors. The LDRI is intended for use by transplant centers, organ procurement organizations, and regulatory agencies and to benefit patients in decision-making. Unlike its predecessors, the proposed LDRI could gain wide acceptance because of its granularity and similarity to the Kidney Donor Risk Index.
Collapse
Affiliation(s)
- Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joshua Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nikhil Ganjoo
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ana Nottigham
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christian Vivar Ramon
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Madeline McCurry
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jacqueline Friskey
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dun Jin
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michaela R Anderson
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jessica Lisowski
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Audrey Le Mahajan
- Division of Infectious Disease, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - A Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Gallop
- Department of Mathematics, West Chester University, West Chester, Pennsylvania, USA
| | - Jesse Hsu
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
4
|
Diamond JM, Anderson MR, Cantu E, Clausen ES, Shashaty MGS, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Lama VN, Patel MG, Singer JP, Hachem RR, Michelson AP, Hsu J, Russell Localio A, Christie JD. Development and validation of primary graft dysfunction predictive algorithm for lung transplant candidates. J Heart Lung Transplant 2024; 43:633-641. [PMID: 38065239 PMCID: PMC10947904 DOI: 10.1016/j.healun.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 11/05/2023] [Accepted: 11/30/2023] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Accurate prediction of PGD risk could inform donor approaches and perioperative care planning. We sought to develop a clinically useful, generalizable PGD prediction model to aid in transplant decision-making. METHODS We derived a predictive model in a prospective cohort study of subjects from 2012 to 2018, followed by a single-center external validation. We used regularized (lasso) logistic regression to evaluate the predictive ability of clinically available PGD predictors and developed a user interface for clinical application. Using decision curve analysis, we quantified the net benefit of the model across a range of PGD risk thresholds and assessed model calibration and discrimination. RESULTS The PGD predictive model included distance from donor hospital to recipient transplant center, recipient age, predicted total lung capacity, lung allocation score (LAS), body mass index, pulmonary artery mean pressure, sex, and indication for transplant; donor age, sex, mechanism of death, and donor smoking status; and interaction terms for LAS and donor distance. The interface allows for real-time assessment of PGD risk for any donor/recipient combination. The model offers decision-making net benefit in the PGD risk range of 10% to 75% in the derivation centers and 2% to 10% in the validation cohort, a range incorporating the incidence in that cohort. CONCLUSION We developed a clinically useful PGD predictive algorithm across a range of PGD risk thresholds to support transplant decision-making, posttransplant care, and enrich samples for PGD treatment trials.
Collapse
Affiliation(s)
- Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Michaela R Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily S Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Scott M Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Laurie D Snyder
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Ghundeep S Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Mrunal G Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P Singer
- Division of Pulmonary and Critical Care Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
5
|
Wong KHM, Hsin KYM. Primary graft dysfunction in lung transplantation: still a thorn in the side of lung transplant. J Thorac Dis 2024; 16:1-5. [PMID: 38410540 PMCID: PMC10894369 DOI: 10.21037/jtd-23-1618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 12/12/2023] [Indexed: 02/28/2024]
Affiliation(s)
- Kwun Hung Max Wong
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong, China
| | | |
Collapse
|
6
|
Diamond JM, Cantu E, Calfee CS, Anderson MR, Clausen ES, Shashaty MGS, Courtwright AM, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Todd JL, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Weinacker AB, Lama VN, Patel MG, Singer JP, Hsu J, Localio AR, Christie JD. The Impact of Donor Smoking on Primary Graft Dysfunction and Mortality after Lung Transplantation. Am J Respir Crit Care Med 2024; 209:91-100. [PMID: 37734031 PMCID: PMC10870879 DOI: 10.1164/rccm.202303-0358oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/21/2023] [Indexed: 09/23/2023] Open
Abstract
Rationale: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Prior studies implicated proxy-defined donor smoking as a risk factor for PGD and mortality. Objectives: We aimed to more accurately assess the impact of donor smoke exposure on PGD and mortality using quantitative smoke exposure biomarkers. Methods: We performed a multicenter prospective cohort study of lung transplant recipients enrolled in the Lung Transplant Outcomes Group cohort between 2012 and 2018. PGD was defined as grade 3 at 48 or 72 hours after lung reperfusion. Donor smoking was defined using accepted thresholds of urinary biomarkers of nicotine exposure (cotinine) and tobacco-specific nitrosamine (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol [NNAL]) in addition to clinical history. The donor smoking-PGD association was assessed using logistic regression, and survival analysis was performed using inverse probability of exposure weighting according to smoking category. Measurements and Main Results: Active donor smoking prevalence varied by definition, with 34-43% based on urinary cotinine, 28% by urinary NNAL, and 37% by clinical documentation. The standardized risk of PGD associated with active donor smoking was higher across all definitions, with an absolute risk increase of 11.5% (95% confidence interval [CI], 3.8% to 19.2%) by urinary cotinine, 5.7% (95% CI, -3.4% to 14.9%) by urinary NNAL, and 6.5% (95% CI, -2.8% to 15.8%) defined clinically. Donor smoking was not associated with differential post-lung transplant survival using any definition. Conclusions: Donor smoking associates with a modest increase in PGD risk but not with increased recipient mortality. Use of lungs from smokers is likely safe and may increase lung donor availability. Clinical trial registered with www.clinicaltrials.gov (NCT00552357).
Collapse
Affiliation(s)
- Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Carolyn S. Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Michaela R. Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Emily S. Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | | | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Maria M. Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | | | | | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jamie L. Todd
- Division of Pulmonary and Critical Care Medicine and
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F. McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D. Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B. Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Gundeep S. Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Ann B. Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N. Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan; and
| | - Mrunal G. Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P. Singer
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| |
Collapse
|
7
|
Subramaniam K, Loor G, Chan EG, Bottiger BA, Ius F, Hartwig MG, Daoud D, Zhang Q, Wei Q, Villavicencio-Theoduloz MA, Osho AA, Chandrashekaran S, Noguchi Machuca T, Van Raemdonck D, Neyrinck A, Toyoda Y, Kashem MA, Huddleston S, Ryssel NR, Sanchez PG. Intraoperative Red Blood Cell Transfusion and Primary Graft Dysfunction After Lung Transplantation. Transplantation 2023; 107:1573-1579. [PMID: 36959119 DOI: 10.1097/tp.0000000000004545] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND In this international, multicenter study of patients undergoing lung transplantation (LT), we explored the association between the amount of intraoperative packed red blood cell (PRBC) transfusion and occurrence of primary graft dysfunction (PGD) and associated outcomes. METHODS The Extracorporeal Life Support in LT Registry includes data on LT recipients from 9 high-volume (>40 transplants/y) transplant centers (2 from Europe, 7 from the United States). Adult patients who underwent bilateral orthotopic lung transplant from January 2016 to January 2020 were included. The primary outcome of interest was the occurrence of grade 3 PGD in the first 72 h after LT. RESULTS We included 729 patients who underwent bilateral orthotopic lung transplant between January 2016 and November 2020. LT recipient population tertiles based on the amount of intraoperative PRBC transfusion (0, 1-4, and >4 units) were significantly different in terms of diagnosis, age, gender, body mass index, mean pulmonary artery pressure, lung allocation score, hemoglobin, prior chest surgery, preoperative hospitalization, and extracorporeal membrane oxygenation requirement. Inverse probability treatment weighting logistic regression showed that intraoperative PRBC transfusion of >4 units was significantly ( P < 0.001) associated with grade 3 PGD within 72 h (odds ratio [95% confidence interval], 2.2 [1.6-3.1]). Inverse probability treatment weighting analysis excluding patients with extracorporeal membrane oxygenation support produced similar findings (odds ratio [95% confidence interval], 2.4 [1.7-3.4], P < 0.001). CONCLUSIONS In this multicenter, international registry study of LT patients, intraoperative transfusion of >4 units of PRBCs was associated with an increased risk of grade 3 PGD within 72 h. Efforts to improve post-LT outcomes should include perioperative blood conservation measures.
Collapse
Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Gabriel Loor
- Division of Cardiothoracic Transplantation and Mechanical Circulatory Support, Baylor College of Medicine, Houston, TX
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Daoud Daoud
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Qianzi Zhang
- Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Qi Wei
- Department of Statistics, Phastar Inc, Durham, NC
| | | | - Asishana A Osho
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, MA
| | - Satish Chandrashekaran
- Department of Pulmonary and Critical Care, McKelvey Lung Transplant Center, Emory University Hospital, Atlanta, GA
| | | | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Division of Anesthesiology and Algology, University Hospitals Leuven, Leuven, Belgium
| | - Yoshiya Toyoda
- Division of Cardiovascular Surgery, Temple University, Philadelphia, PA
| | - Mohammed A Kashem
- Division of Cardiovascular Surgery, Temple University, Philadelphia, PA
| | - Stephen Huddleston
- Division of Cardiothoracic Surgery, University of Minnesota Medical School, Minneapolis, MI
| | - Naomi R Ryssel
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
8
|
Vajter J, Vachtenheim J, Prikrylova Z, Berousek J, Vymazal T, Lischke R, Martin AK, Durila M. Effect of targeted coagulopathy management and 5% albumin as volume replacement therapy during lung transplantation on allograft function: a secondary analysis of a randomized clinical trial. BMC Pulm Med 2023; 23:80. [PMID: 36894877 PMCID: PMC9996868 DOI: 10.1186/s12890-023-02372-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/27/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) after lung transplantation (LuTx) contributes substantially to early postoperative morbidity. Both intraoperative transfusion of a large amount of blood products during the surgery and ischemia-reperfusion injury after allograft implantation play an important role in subsequent PGD development. METHODS We have previously reported a randomized clinical trial of 67 patients where point of care (POC) targeted coagulopathy management and intraoperative administration of 5% albumin led to significant reduction of blood loss and blood product consumption during the lung transplantation surgery. A secondary analysis of the randomized clinical trial evaluating the effect of targeted coagulopathy management and intraoperative administration of 5% albumin on early lung allograft function after LuTx and 1-year survival was performed. RESULTS Compared to the patients in the control (non-POC) group, those in study (POC) group showed significantly superior graft function, represented by the Horowitz index (at 72 h after transplantation 402.87 vs 308.03 with p < 0.001, difference between means: 94.84, 95% CI: 60.18-129.51). Furthermore, the maximum doses of norepinephrine administered during first 24 h were significantly lower in the POC group (0.193 vs 0.379 with p < 0.001, difference between the means: 0.186, 95% CI: 0.105-0.267). After dichotomization of PGD (0-1 vs 2-3), significant difference between the non-POC and POC group occurred only at time point 72, when PGD grade 2-3 developed in 25% (n = 9) and 3.2% (n = 1), respectively (p = 0.003). The difference in 1-year survival was not statistically significant (10 patients died in non-POC group vs. 4 patients died in POC group; p = 0.17). CONCLUSIONS Utilization of a POC targeted coagulopathy management combined with Albumin 5% as primary resuscitative fluid may improve early lung allograft function, provide better circulatory stability during the early post-operative period, and have potential to decrease the incidence of PGD without negative effect on 1-year survival. TRIAL REGISTRATION This clinical trial was registered at ClinicalTrials.gov (NCT03598907).
Collapse
Affiliation(s)
- Jaromir Vajter
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jiri Vachtenheim
- Prague Lung Transplant Program, 3rd Department of Surgery, First Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic.
| | - Zuzana Prikrylova
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jan Berousek
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Tomas Vymazal
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Robert Lischke
- Prague Lung Transplant Program, 3rd Department of Surgery, First Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Miroslav Durila
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| |
Collapse
|
9
|
O'Connor C, Munoz FM, Gazzaneo MC, Melicoff E, Das S, Lam F, Coss-Bu JA. Application of organ dysfunction assessment scores following pediatric lung transplantation. Clin Transplant 2023; 37:e14863. [PMID: 36480657 DOI: 10.1111/ctr.14863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 10/12/2022] [Accepted: 10/28/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Organ dysfunction (OD) after lung transplantation can reflect preoperative organ failure, intraoperative acute organ damage and post-operative complications. We assessed two OD scoring systems, both the PEdiatric Logistic Organ Dysfunction (PELOD) and the pediatric Sequential Organ Failure Assessment (pSOFA) scores, in recognizing risk factors for morbidity as well as recipients with prolonged post-transplant morbidity. DESIGN Medical records of recipients from January 2009 to March 2016 were reviewed. PELOD and pSOFA scores were calculated on post-transplant days 1-3. Risk factors assessed included cystic fibrosis (CF), prolonged surgical time and worst primary graft dysfunction (PGD) score amongst others. Patients were classified into three groups based on their initial scores (group A) and subsequent trends either uptrending (group B) or downtrending (group C). Morbidity outcomes were compared between these groups. RESULTS Total 98 patients were enrolled aged 0-20 years. Risk factors for higher pSOFA scores ≥ 5 on day 1 included non-CF diagnosis and worst PGD scores (p = .0006 and p = .03, respectively). Kruskal Wallis analysis comparing pSOFA group A versus B versus C scores showed significantly prolonged ventilatory days (median 1 vs. 4 vs. 2, p = .0028) and ICU days (median 4 vs. 10 vs. 6, p = .007). Similarly, PELOD group A versus B versus C scores showed significantly prolonged ventilatory days (1 vs. 5 vs. 2, p = < .0001). CONCLUSION Implementing pSOFA scores bedside is a more effective tool compared to PELOD in identifying risk factors for worsened OD post-lung transplant and can be valuable in providing direction on morbidity outcomes in the ICU.
Collapse
Affiliation(s)
- Chinyere O'Connor
- McGovern Medical School, UT Health Science Center at Houston, Houston, Texas, USA.,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA.,Division of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas, USA
| | - Flor M Munoz
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA.,Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Section of Infectious Diseases and Transplant, Texas Children's Hospital, Houston, Texas, USA
| | - Maria C Gazzaneo
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA.,Division of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas, USA.,Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Section of Pulmonary Medicine and Lung Transplant, Texas Children's Hospital, Houston, Texas, USA
| | - Ernestina Melicoff
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA.,Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Section of Pulmonary Medicine and Lung Transplant, Texas Children's Hospital, Houston, Texas, USA
| | - Shailendra Das
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA.,Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Section of Pulmonary Medicine and Lung Transplant, Texas Children's Hospital, Houston, Texas, USA
| | - Fong Lam
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA.,Division of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas, USA.,Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jorge A Coss-Bu
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA.,Division of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas, USA.,Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
10
|
Abstract
Lung transplantation provides a treatment option for many individuals with advanced lung disease due to cystic fibrosis (CF). Since the first transplants for CF in the 1980s, survival has improved and the opportunity for transplant has expanded to include individuals who previously were not considered candidates for transplant. Criteria to be a transplant candidate vary significantly among transplant programs, highlighting that the engagement in more than one transplant program may be necessary. Individuals with highly resistant CF pathogens, malnutrition, osteoporosis, CF liver disease, and other comorbidities may be suitable candidates for lung transplant, or if needed, multi-organ transplant. The transplant process involves several phases, from discussion of prognosis and referral to a transplant center, to transplant evaluation, to listing, transplant surgery, and care after transplant. While the availability of highly effective CF transmembrane conductance regulator (CFTR) modulators for many individuals with CF has improved lung function and slowed progression to respiratory failure, early discussion regarding transplant as a treatment option and referral to a transplant program are critical to maximizing opportunity and optimizing patient and family experience. The decision to be evaluated for transplant and to list for transplant are distinct, and early referral may provide a treatment option that can be urgently executed if needed. Survival after transplant for CF is improving, to a median survival of approximately 10 years, and most transplant survivors enjoy significant improvement in quality of life.
Collapse
|
11
|
Cantu E, Diamond JM, Cevasco M, Suzuki Y, Crespo M, Clausen E, Dallara L, Ramon CV, Harmon MT, Bermudez C, Benvenuto L, Anderson M, Wille KM, Weinacker A, Dhillon GS, Orens J, Shah P, Merlo C, Lama V, McDyer J, Snyder L, Palmer S, Hartwig M, Hage CA, Singer J, Calfee C, Kukreja J, Greenland JR, Ware LB, Localio R, Hsu J, Gallop R, Christie JD. Contemporary trends in PGD incidence, outcomes, and therapies. J Heart Lung Transplant 2022; 41:1839-1849. [PMID: 36216694 PMCID: PMC9990084 DOI: 10.1016/j.healun.2022.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We sought to describe trends in extracorporeal membrane oxygenation (ECMO) use, and define the impact on PGD incidence and early mortality in lung transplantation. METHODS Patients were enrolled from August 2011 to June 2018 at 10 transplant centers in the multi-center Lung Transplant Outcomes Group prospective cohort study. PGD was defined as Grade 3 at 48 or 72 hours, based on the 2016 PGD ISHLT guidelines. Logistic regression and survival models were used to contrast between group effects for event (i.e., PGD and Death) and time-to-event (i.e., death, extubation, discharge) outcomes respectively. Both modeling frameworks accommodate the inclusion of potential confounders. RESULTS A total of 1,528 subjects were enrolled with a 25.7% incidence of PGD. Annual PGD incidence (14.3%-38.2%, p = .0002), median LAS (38.0-47.7 p = .009) and the use of ECMO salvage for PGD (5.7%-20.9%, p = .007) increased over the course of the study. PGD was associated with increased 1 year mortality (OR 1.7 [95% C.I. 1.2, 2.3], p = .0001). Bridging strategies were not associated with increased mortality compared to non-bridged patients (p = .66); however, salvage ECMO for PGD was significantly associated with increased mortality (OR 1.9 [1.3, 2.7], p = .0007). Restricted mean survival time comparison at 1-year demonstrated 84.1 days lost in venoarterial salvaged recipients with PGD when compared to those without PGD (ratio 1.3 [1.1, 1.5]) and 27.2 days for venovenous with PGD (ratio 1.1 [1.0, 1.4]). CONCLUSIONS PGD incidence continues to rise in modern transplant practice paralleled by significant increases in recipient severity of illness. Bridging strategies have increased but did not affect PGD incidence or mortality. PGD remains highly associated with mortality and is increasingly treated with salvage ECMO.
Collapse
Affiliation(s)
- Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yoshi Suzuki
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Dallara
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian V Ramon
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael T Harmon
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Michaela Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Keith M Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ann Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Gundeep S Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Jonathan Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Christian Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Vibha Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan
| | - John McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Laurie Snyder
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Scott Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Matt Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chadi A Hage
- Division of Pulmonary, Allergy, Critical Care, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan Singer
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, California
| | - Carolyn Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, California
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Russel Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Gallop
- Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
12
|
Bonneau S, Landry C, Bégin S, Adam D, Villeneuve L, Clavet-Lanthier MÉ, Dasilva A, Charles E, Dumont BL, Neagoe PE, Brochiero E, Menaouar A, Nasir B, Stevens LM, Ferraro P, Noiseux N, Sirois MG. Correlation between Neutrophil Extracellular Traps (NETs) Expression and Primary Graft Dysfunction Following Human Lung Transplantation. Cells 2022; 11:3420. [PMID: 36359815 PMCID: PMC9656095 DOI: 10.3390/cells11213420] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/19/2022] [Accepted: 10/28/2022] [Indexed: 09/08/2023] Open
Abstract
Primary graft dysfunction (PGD) is characterized by alveolar epithelial and vascular endothelial damage and inflammation, lung edema and hypoxemia. Up to one-third of recipients develop the most severe form of PGD (Grade 3; PGD3). Animal studies suggest that neutrophils contribute to the inflammatory process through neutrophil extracellular traps (NETs) release (NETosis). NETs are composed of DNA filaments decorated with granular proteins contributing to vascular occlusion associated with PGD. The main objective was to correlate NETosis in PGD3 (n = 9) versus non-PGD3 (n = 27) recipients in an exploratory study. Clinical data and blood samples were collected from donors and recipients pre-, intra- and postoperatively (up to 72 h). Inflammatory inducers of NETs' release (IL-8, IL-6 and C-reactive protein [CRP]) and components (myeloperoxidase [MPO], MPO-DNA complexes and cell-free DNA [cfDNA]) were quantified by ELISA. When available, histology, immunohistochemistry and immunofluorescence techniques were performed on lung biopsies from donor grafts collected during the surgery to evaluate the presence of activated neutrophils and NETs. Lung biopsies from donor grafts collected during transplantation presented various degrees of vascular occlusion including neutrophils undergoing NETosis. Additionally, in recipients intra- and postoperatively, circulating inflammatory (IL-6, IL-8) and NETosis biomarkers (MPO-DNA, MPO, cfDNA) were up to 4-fold higher in PGD3 recipients compared to non-PGD3 (p = 0.041 to 0.001). In summary, perioperative elevation of NETosis biomarkers is associated with PGD3 following human lung transplantation and these biomarkers might serve to identify recipients at risk of PGD3 and initiate preventive therapies.
Collapse
Affiliation(s)
- Steven Bonneau
- Research Center—Montreal Heart Institute, 5000 Belanger St., Montreal, QC H1T 1C8, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
| | - Caroline Landry
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, 2900 Blvd Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
| | - Stéphanie Bégin
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
| | - Damien Adam
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, 2900 Blvd Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
| | - Louis Villeneuve
- Research Center—Montreal Heart Institute, 5000 Belanger St., Montreal, QC H1T 1C8, Canada
| | | | - Ariane Dasilva
- Research Center—Montreal Heart Institute, 5000 Belanger St., Montreal, QC H1T 1C8, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
| | - Elcha Charles
- Research Center—Montreal Heart Institute, 5000 Belanger St., Montreal, QC H1T 1C8, Canada
- Department of Pharmacology and Physiology, Faculty of Medicine, Université de Montréal, 2900 Blvd Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
| | - Benjamin L. Dumont
- Research Center—Montreal Heart Institute, 5000 Belanger St., Montreal, QC H1T 1C8, Canada
- Department of Pharmacology and Physiology, Faculty of Medicine, Université de Montréal, 2900 Blvd Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
| | - Paul-Eduard Neagoe
- Research Center—Montreal Heart Institute, 5000 Belanger St., Montreal, QC H1T 1C8, Canada
| | - Emmanuelle Brochiero
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, 2900 Blvd Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
| | - Ahmed Menaouar
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
| | - Basil Nasir
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, 2900 Blvd Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
| | - Louis-Mathieu Stevens
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, 2900 Blvd Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
| | - Pasquale Ferraro
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, 2900 Blvd Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
| | - Nicolas Noiseux
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 900 Saint-Denis St, Montreal, QC H2X 0A9, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, 2900 Blvd Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
| | - Martin G. Sirois
- Research Center—Montreal Heart Institute, 5000 Belanger St., Montreal, QC H1T 1C8, Canada
- Department of Pharmacology and Physiology, Faculty of Medicine, Université de Montréal, 2900 Blvd Édouard-Montpetit, Montreal, QC H3T 1J4, Canada
| |
Collapse
|
13
|
Plasma protein biomarkers for primary graft dysfunction after lung transplantation: a single-center cohort analysis. Sci Rep 2022; 12:16137. [PMID: 36167867 PMCID: PMC9515157 DOI: 10.1038/s41598-022-20085-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/08/2022] [Indexed: 11/08/2022] Open
Abstract
The clinical use of circulating biomarkers for primary graft dysfunction (PGD) after lung transplantation has been limited. In a prospective single-center cohort, we examined the use of plasma protein biomarkers as indicators of PGD severity and duration after lung transplantation. The study comprised 40 consecutive lung transplant patients who consented to blood sample collection immediately pretransplant and at 6, 24, 48, and 72 h after lung transplant. An expert grader determined the severity and duration of PGD and scored PGD at T0 (6 h after reperfusion), T24, T48, and T72 h post-reperfusion using the 2016 ISHLT consensus guidelines. A bead-based multiplex assay was used to measure 27 plasma proteins including cytokines, growth factors, and chemokines. Enzyme-linked immunoassay was used to measure cell injury markers including M30, M65, soluble receptor of advanced glycation end-products (sRAGE), and plasminogen activator inhibitor-1 (PAI-1). A pairwise comparisons analysis was used to assess differences in protein levels between PGD severity scores (1, 2, and 3) at T0, T24, T48, and T72 h. Sensitivity and temporal analyses were used to explore the association of protein expression patterns and PGD3 at T48-72 h (the most severe, persistent form of PGD). We used the Benjamini-Hochberg method to adjust for multiple testing. Of the 40 patients, 22 (55%) had PGD3 at some point post-transplant from T0 to T72 h; 12 (30%) had PGD3 at T48-72 h. In the pairwise comparison, we identified a robust plasma protein expression signature for PGD severity. In the sensitivity analysis, using a linear model for microarray data, we found that differential perioperative expression of IP-10, MIP1B, RANTES, IL-8, IL-1Ra, G-CSF, and PDGF-BB correlated with PGD3 development at T48-72 h (FDR < 0.1 and p < 0.05). In the temporal analysis, using linear mixed modeling with overlap weighting, we identified unique protein patterns in patients who did or did not develop PGD3 at T48-72 h. Our findings suggest that unique inflammatory protein expression patterns may be informative of PGD severity and duration. PGD biomarker panels may improve early detection of PGD, predict its clinical course, and help monitor treatment efficacy in the current era of lung transplantation.
Collapse
|
14
|
Foroutan F, Malik A, Clark KE, Buchan TA, Yang H, Cheong GHL, Pezzutti O, Kim I, Gupta R, Tan C, Samman A, Friesen EL, Akhtar A, Rigobon A, Stein M, Nunez JJY, Sidhu A, Heels-Ansdell D, Guyatt G, Meade MO. Predictors of 1-year Mortality after Adult Lung Transplantation: Systematic Review and Meta-analyses. J Heart Lung Transplant 2022; 41:937-951. [DOI: 10.1016/j.healun.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 03/07/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022] Open
|
15
|
Martin AK. Primary Graft Dysfunction: The Final Frontier for Perioperative Lung Transplantation Management. J Cardiothorac Vasc Anesth 2022; 36:805-806. [PMID: 35031219 DOI: 10.1053/j.jvca.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 12/06/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, FL
| |
Collapse
|
16
|
Marczin N, de Waal EEC, Hopkins PMA, Mulligan MS, Simon A, Shaw AD, Van Raemdonck D, Neyrinck A, Gries CJ, Algotsson L, Szegedi L, von Dossow V. International consensus recommendations for anesthetic and intensive care management of lung transplantation. An EACTAIC, SCA, ISHLT, ESOT, ESTS, and AST approved document. J Heart Lung Transplant 2021; 40:1327-1348. [PMID: 34732281 DOI: 10.1016/j.healun.2021.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Nandor Marczin
- Harefield Hospital Royal Brompton and Harefield Hospitals, Imperial College London, London, United Kingdom, Semmelweis University, Budapest, Hungary.
| | | | | | | | - Andre Simon
- Harefield Hospital RBHT, London, United Kingdom
| | | | | | | | | | | | - Laszlo Szegedi
- Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | | | | |
Collapse
|
17
|
Fessler J, Vallée A, Guirimand A, Sage E, Glorion M, Roux A, Brugière O, Parquin F, Zuber B, Cerf C, Vasse M, Pascreau T, Fischler M, Ichai C, Guen ML. Blood Lactate During Double-Lung Transplantation: A Predictor of Grade-3 Primary Graft Dysfunction. J Cardiothorac Vasc Anesth 2021; 36:794-804. [PMID: 34879926 DOI: 10.1053/j.jvca.2021.10.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Many prognostic factors of grade-3 primary graft dysfunction at postoperative day 3 (PGD3-T72) have been reported, but intraoperative blood lactate level has not been studied. The present retrospective study was done to test the hypothesis that intraoperative blood lactate level (BLL) could be a predictor of PGD3-T72 after double-lung transplantation. DESIGN Retrospective monocentric cohort study. SETTING Foch University Hospital, Suresnes, France. PARTICIPANTS Patients having received a double-lung transplantation between 2012 and 2019. Patients transplanted twice during the study period, having undergone a multiorgan transplantation, or cardiopulmonary bypass, and those under preoperative extracorporeal membrane oxygenation, were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analysis was performed on a cohort of 449 patients. Seventy-two (16%) patients had a PGD3-T72. Blood lactate level increased throughout surgery to reach a median value of 2.2 (1.6-3.2) mmol/L in the No-PGD3-T72 group and 3.4 (2.3-5.0) mmol/L in the PGD3-T72 group after second lung implantation. The best predictive model for PGD3-T72 was obtained adding a lactate threshold of 2.6 mmol/L at the end of surgery to the clinical model, and the area under the curve was 0.867, with a sensitivity = 76.9% and specificity = 85.4%. Repeated-measures mixed model of BLL during surgery remained significant after adjustment for covariates (F ratio= 4.22, p < 0.001 for interaction). CONCLUSIONS Blood lactate level increases during surgery and reaches a maximum after the second lung implantation. A value below the threshold of 2.6 mmol/L at the end of surgery has a high negative predictive value for the occurrence of a grade-3 primary graft dysfunction at postoperative day 3.
Collapse
Affiliation(s)
- Julien Fessler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France.
| | - Alexandre Vallée
- Department of Clinical Research and Innovation, Hôpital Foch, Suresnes, France
| | - Avit Guirimand
- Department of Anesthesiology, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Edouard Sage
- Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France; Department of Thoracic Surgery, Hôpital Foch, Suresnes, France
| | - Matthieu Glorion
- Department of Thoracic Surgery, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Antoine Roux
- Department of Pneumology, Hôpital Foch, Suresnes, France,; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Olivier Brugière
- Department of Pneumology, Hôpital Foch, Suresnes, France,; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - François Parquin
- Department of Thoracic Surgery, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Benjamin Zuber
- Department of Intensive Care Medicine, Hôpital Foch, Suresnes, France
| | - Charles Cerf
- Department of Intensive Care Medicine, Hôpital Foch, Suresnes, France
| | - Marc Vasse
- Department of Clinical Biology, Hôpital Foch, Suresnes, France; INSERM UMRS-1176, Université Paris-Sud, Orsay
| | - Tiffany Pascreau
- Department of Clinical Biology, Hôpital Foch, Suresnes, France; INSERM UMRS-1176, Université Paris-Sud, Orsay
| | - Marc Fischler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France.
| | - Carole Ichai
- Department of Intensive Care, Hôpital Pasteur, Nice, France; IRCAN INSERM, Nice, France
| | - Morgan Le Guen
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| |
Collapse
|
18
|
Clausen E, Cantu E. Primary graft dysfunction: what we know. J Thorac Dis 2021; 13:6618-6627. [PMID: 34992840 PMCID: PMC8662499 DOI: 10.21037/jtd-2021-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/21/2021] [Indexed: 12/19/2022]
Abstract
Many advances in lung transplant have occurred over the last few decades in the understanding of primary graft dysfunction (PGD) though effective prevention and treatment remain elusive. This review will cover prior understanding of PGD, recent findings, and directions for future research. A consensus statement updating the definition of PGD in 2016 highlights the growing complexity of lung transplant perioperative care taking into account the increasing use of high flow oxygen delivery and pulmonary vasodilators in the current era. PGD, particularly more severe grades, is associated with worse short- and long-term outcomes after transplant such as chronic lung allograft dysfunction. Growing experience have helped identify recipient, donor, and intraoperative risk factors for PGD. Understanding the pathophysiology of PGD has advanced with increasing knowledge of the role of innate immune response, humoral cell immunity, and epithelial cell injury. Supportive care post-transplant with technological advances in extracorporeal membranous oxygenation (ECMO) remain the mainstay of treatment for severe PGD. Future directions include the evolving utility of ex vivo lung perfusion (EVLP) both in PGD research and potential pre-transplant treatment applications. PGD remains an important outcome in lung transplant and the future holds a lot of potential for improvement in understanding its pathophysiology as well as development of preventative therapies and treatment.
Collapse
Affiliation(s)
- Emily Clausen
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
19
|
Dugger DT, Calabrese DR, Gao Y, Deiter F, Tsao T, Maheshwari J, Hays SR, Leard L, Kleinhenz ME, Shah R, Golden J, Kukreja J, Gordon ED, Singer JP, Greenland JR. Lung Allograft Epithelium DNA Methylation Age Is Associated With Graft Chronologic Age and Primary Graft Dysfunction. Front Immunol 2021; 12:704172. [PMID: 34691018 PMCID: PMC8528961 DOI: 10.3389/fimmu.2021.704172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 09/09/2021] [Indexed: 02/04/2023] Open
Abstract
Advanced donor age is a risk factor for poor survival following lung transplantation. However, recent work identifying epigenetic determinants of aging has shown that biologic age may not always reflect chronologic age and that stressors can accelerate biologic aging. We hypothesized that lung allografts that experienced primary graft dysfunction (PGD), characterized by poor oxygenation in the first three post-transplant days, would have increased biologic age. We cultured airway epithelial cells isolated by transbronchial brush at 1-year bronchoscopies from 13 subjects with severe PGD and 15 controls matched on age and transplant indication. We measured epigenetic age using the Horvath epigenetic clock. Linear models were used to determine the association of airway epigenetic age with chronologic ages and PGD status, adjusted for recipient PGD risk factors. Survival models assessed the association with chronic lung allograft dysfunction (CLAD) or death. Distributions of promoter methylation within pathways were compared between groups. DNA methyltransferase (DNMT) activity was quantified in airway epithelial cells under hypoxic or normoxic conditions. Airway epigenetic age appeared younger but was strongly associated with the age of the allograft (slope 0.38 per year, 95% CI 0.27–0.48). There was no correlation between epigenetic age and recipient age (P = 0.96). Epigenetic age was 6.5 years greater (95% CI 1.7–11.2) in subjects who had experienced PGD, and this effect remained significant after adjusting for donor and recipient characteristics (P = 0.03). Epigenetic age was not associated with CLAD-free survival risk (P = 0.11). Analysis of differential methylation of promoters of key biologic pathways revealed hypomethylation in regions related to hypoxia, inflammation, and metabolism-associated pathways. Accordingly, airway epithelial cells cultured in hypoxic conditions showed suppressed DNMT activity. While airway methylation age was primarily determined by donor chronologic age, early injury in the form of PGD was associated with increased allograft epigenetic age. These data show how PGD might suppress key promoter methylation resulting in long-term impacts on the allograft.
Collapse
Affiliation(s)
- Daniel T Dugger
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Daniel R Calabrese
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
| | - Ying Gao
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Fred Deiter
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Tasha Tsao
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Julia Maheshwari
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Steven R Hays
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Lorriana Leard
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Mary Ellen Kleinhenz
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Rupal Shah
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jeff Golden
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jasleen Kukreja
- Department of Surgery, University of California at San Francisco, San Francisco, CA, United States
| | - Erin D Gordon
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jonathan P Singer
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - John R Greenland
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
| |
Collapse
|
20
|
Courtwright AM, Kamoun M, Diamond JM, Kearns J, Ahya VN, Christie JD, Clausen E, Hadjiliadis D, Patel N, Salgado JC, Cevasco M, Cantu EE, Crespo MM, Bermudez CA. Lung Transplantation Outcomes after Crossing Low-Level Donor Specific Antibodies Without Planned Augmented Immunosuppression. Clin Transplant 2021; 35:e14447. [PMID: 34365656 DOI: 10.1111/ctr.14447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/26/2021] [Accepted: 07/27/2021] [Indexed: 11/29/2022]
Abstract
It is unknown whether some donor specific antibodies (DSA) can be crossed at the time of lung transplant without desensitization or augmented induction immunosuppression. This study assessed whether crossing low-level pre-transplant DSA (defined as mean fluorescence intensity (MFI) 1000-6000) without augmented immunosuppression is associated with worse retransplant-free or chronic lung allograft dysfunction (CLAD)-free survival. Of the 458 included recipients, low-level pre-transplant DSA was crossed in 39 (8.6%) patients. The median follow-up time was 2.2 years. There were 15 (38.5%) patients with Class I DSA and 24 (61.5%) with Class II DSA. There was no difference in adjusted overall retransplant-free survival between recipients where pre-transplant DSA was and was not crossed (HR: 0.98 (95% CI = 0.49-1.99), p = 0.96). There was also no difference in CLAD-free survival (HR: 0.71 (95% CI = 0.38-1.33), p = 0.28). There was no difference in Grade 3 PGD at 72 hours (OR: 1.13 (95% CI = 0.52-2.48), p = 0.75) or definite or probable AMR (HR: 2.22 (95% CI = 0.64-7.61), p = 0.21). Lung transplantation in the presence of low-level DSA without planned augmented immunosuppression is not associated with worse overall or CLAD-free survival among recipients with intermediate-term follow-up. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Malek Kamoun
- Pathology and Laboratory Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Joshua M Diamond
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jane Kearns
- Pathology and Laboratory Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Vivek N Ahya
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jason D Christie
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Emily Clausen
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Denis Hadjiliadis
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Namrata Patel
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Juan C Salgado
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Edward E Cantu
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Maria M Crespo
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Christian A Bermudez
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
21
|
Kim SJ, Azour L, Hutchinson BD, Shirsat H, Zhou F, Narula N, Moreira AL, Angel L, Ko JP, Moore WH. Imaging Course of Lung Transplantation: From Patient Selection to Postoperative Complications. Radiographics 2021; 41:1043-1063. [PMID: 34197245 DOI: 10.1148/rg.2021200173] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Lung transplant is increasingly performed for the treatment of end-stage lung disease. As the number of lung transplants and transplant centers continues to rise, radiologists will more frequently participate in the care of patients undergoing lung transplant, both before and after transplant. Potential donors and recipients undergo chest radiography and CT as part of their pretransplant assessment to evaluate for contraindications to transplant and to aid in surgical planning. After transplant, recipients undergo imaging during the postoperative hospitalization and also in the long-term outpatient setting. Radiologists encounter a wide variety of conditions leading to end-stage lung disease and a myriad of posttransplant complications, some of which are unique to lung transplantation. Familiarity with these pathologic conditions, including their imaging findings and their temporal relationship to the transplant, is crucial to accurate radiologic interpretation. Knowledge of the surgical techniques and expected postoperative appearance prevents confusing normal posttransplant imaging findings with complications. A basic understanding of the indications, contraindications, and surgical considerations of lung transplant aids in imaging interpretation and protocoling and also facilitates communication between radiologists and transplant physicians. Despite medical and surgical advances over the past several decades, lung transplant recipients currently have an average posttransplant life expectancy of only 6.7 years. As members of the transplant team, radiologists can help maximize patient survival and hopefully increase posttransplant life expectancy and quality of life in the coming decades. ©RSNA, 2021 An invited commentary by Bierhals is available online. Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Stacy J Kim
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Lea Azour
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Barry D Hutchinson
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Hemlata Shirsat
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Fang Zhou
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Navneet Narula
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Andre L Moreira
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Luis Angel
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - Jane P Ko
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| | - William H Moore
- From the Department of Radiology (S.J.K., L.A., J.P.K., W.H.M.), Department of Pathology (F.Z., N.N., A.L.M.), Department of Pulmonology, Critical Care, and Sleep Medicine (L.A.), and Transplant Institute (L.A.), New York University, New York, NY; Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.D.H.); and Department of Pathology, Vancouver Island Health Authority and University of British Columbia, Victoria, British Columbia, Canada (H.S.)
| |
Collapse
|
22
|
Li C, Patel K, Tu Z, Yang X, Kulik L, Alawieh A, Allen P, Cheng Q, Wallace C, Kilkenny J, Kwon J, Gibney B, Cantu E, Sharma A, Pipkin M, Machuca T, Emtiazjoo A, Goddard M, Holers VM, Nadig S, Christie J, Tomlinson S, Atkinson C. A novel injury site-natural antibody targeted complement inhibitor protects against lung transplant injury. Am J Transplant 2021; 21:2067-2078. [PMID: 33210808 PMCID: PMC8246004 DOI: 10.1111/ajt.16404] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 01/25/2023]
Abstract
Complement is known to play a role in ischemia and reperfusion injury (IRI). A general paradigm is that complement is activated by self-reactive natural IgM antibodies (nAbs), after they engage postischemic neoepitopes. However, a role for nAbs in lung transplantation (LTx) has not been explored. Using mouse models of LTx, we investigated the role of two postischemic neoepitopes, modified annexin IV (B4) and a subset of phospholipids (C2), in LTx. Antibody deficient Rag1-/- recipient mice were protected from LTx IRI. Reconstitution with either B4 or C2nAb restored IRI, with C2 significantly more effective than B4 nAb. Based on these information, we developed/characterized a novel complement inhibitor composed of single-chain antibody (scFv) derived from the C2 nAb linked to Crry (C2scFv-Crry), a murine inhibitor of C3 activation. Using an allogeneic LTx, in which recipients contain a full nAb repertoire, C2scFv-Crry targeted to the LTx, inhibited IRI, and delayed acute rejection. Finally, we demonstrate the expression of the C2 neoepitope in human donor lungs, highlighting the translational potential of this approach.
Collapse
Affiliation(s)
- Changhai Li
- The Hepatic Surgery Centre at Tongji Hospital, Tongji Medical College, HUST, Wuhan, China
- Hubei Province for the Clinical Medicine Research Center of Hepatic Surgery, Key Laboratory of Organ Transplantation, Ministry of Education and Ministry of Public Health, Wuhan, China
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Kunal Patel
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Zhenxiao Tu
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Hepatic and Vascular Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofeng Yang
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Liudmila Kulik
- Department of Medicine and Immunology, University of Colorado Denver, Aurora, Colorado, USA
| | - Ali Alawieh
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Patterson Allen
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Qi Cheng
- The Hepatic Surgery Centre at Tongji Hospital, Tongji Medical College, HUST, Wuhan, China
- Hubei Province for the Clinical Medicine Research Center of Hepatic Surgery, Key Laboratory of Organ Transplantation, Ministry of Education and Ministry of Public Health, Wuhan, China
| | - Caroline Wallace
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Jane Kilkenny
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Jennie Kwon
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Barry Gibney
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Ashish Sharma
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Mauricio Pipkin
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Tiago Machuca
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Amir Emtiazjoo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | - Martin Goddard
- Pathology Department, Papworth Hospital, NHS Trust, Papworth Everard, Cambridge, UK
| | - V Michael Holers
- Department of Medicine and Immunology, University of Colorado Denver, Aurora, Colorado, USA
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Satish Nadig
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- South Carolina Investigators in Transplantation, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jason Christie
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen Tomlinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, University of Florida, Gainesville, Florida, USA
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Carl Atkinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- South Carolina Investigators in Transplantation, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
23
|
Daoud D, Chacon Alberty L, Wei Q, Hochman Mendez C, Virk MHM, Mase J, Jindra P, Cusick M, Choi H, Debolske N, Sampaio LC, Taylor DA, Loor G. Incidence of primary graft dysfunction is higher according to the new ISHLT 2016 guidelines and correlates with clinical and molecular risk factors. J Thorac Dis 2021; 13:3426-3442. [PMID: 34277039 PMCID: PMC8264697 DOI: 10.21037/jtd-20-3564] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/14/2021] [Indexed: 12/18/2022]
Abstract
Background Primary graft dysfunction (PGD) is the most important determinant of morbidity and mortality after lung transplantation, but its definition has evolved over the past decade. The implications of this refinement in clinical definition have not been evaluated. In this single-center study, we compared PGD incidence, risk factors, and outcomes using the 2005 and the updated-2016 International Society of Heart and Lung Transplantation guidelines for PGD grading in lung transplant patients. Methods In this retrospective study, we extracted data from the medical records of 127 patients who underwent lung transplantation between 1/1/2016–12/31/2018. PGD was defined as PGD3 present at 48 and/or 72 hours post-reperfusion. We used the 2005 and the updated 2016 guidelines to assess clinical risk factors, outcomes, and baseline biomarkers for PGD. Results On the basis of the 2016 and 2005 guidelines, we identified PGD in 37% and 26% of patients, respectively. PGD was significantly associated with extracorporeal life support, large body mass index, and restrictive lung disease using the 2016 but not the 2005 guidelines. Based on the 2016 guidelines, pretransplant levels of several biomarkers were associated with PGD; using the 2005 guidelines, only increased interleukin-2 levels were significantly associated with PGD. No preoperative biomarkers were associated with PGD using either guidelines after adjusting for clinical variables. Postoperative morbidity and 1-year mortality were similar regardless of guidelines used. Conclusions Our findings suggest that refinements in the PGD scoring system have improved the detection of graft injury and associated risk factors without changing its ability to predict postoperative morbidity and mortality.
Collapse
Affiliation(s)
- Daoud Daoud
- Michael E DeBakey Department of Surgery, Division of Cardiopulmonary Transplantation and Mechanical Circulatory Support, Baylor College of Medicine, Houston, TX, USA
| | | | - Qi Wei
- Michael E DeBakey Department of Surgery, Division of Cardiopulmonary Transplantation and Mechanical Circulatory Support, Baylor College of Medicine, Houston, TX, USA
| | - Camila Hochman Mendez
- Department of Regenerative Medicine Research, Texas Heart Institute, Houston, TX, USA
| | - Muhammad Hassan Masood Virk
- Center for Antimicrobial Resistance and Microbial Genomics (CARMiG), Department of Internal Medicine, Division of Infectious Diseases, University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Jonathan Mase
- Department of Regenerative Medicine Research, Texas Heart Institute, Houston, TX, USA
| | - Peter Jindra
- Michael E DeBakey Department of Surgery, Division of Cardiopulmonary Transplantation and Mechanical Circulatory Support, Baylor College of Medicine, Houston, TX, USA
| | - Matthew Cusick
- Michael E DeBakey Department of Surgery, Division of Cardiopulmonary Transplantation and Mechanical Circulatory Support, Baylor College of Medicine, Houston, TX, USA
| | - Hyewon Choi
- Michael E DeBakey Department of Surgery, Division of Cardiopulmonary Transplantation and Mechanical Circulatory Support, Baylor College of Medicine, Houston, TX, USA
| | - Natalie Debolske
- Michael E DeBakey Department of Surgery, Division of Cardiopulmonary Transplantation and Mechanical Circulatory Support, Baylor College of Medicine, Houston, TX, USA
| | - Luiz C Sampaio
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Gabriel Loor
- Michael E DeBakey Department of Surgery, Division of Cardiopulmonary Transplantation and Mechanical Circulatory Support, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
24
|
Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD) is a devastating complication in the acute postoperative lung transplant period, associated with high short-term mortality and chronic rejection. We review its definition, pathophysiology, risk factors, prevention, treatment strategies, and future research directions. RECENT FINDINGS New analyses suggest donation after circulatory death and donation after brain death donors have similar PGD rates, whereas donors >55 years are not associated with increased PGD risk. Recipient pretransplant diastolic dysfunction and overweight or obese recipients with predominant abdominal subcutaneous adipose tissue have increased PGD risk. Newly identified recipient biomarkers and donor and recipient genes increase PGD risk, but their clinical utility remains unclear. Mixed data still exists regarding cold ischemic time and PGD risk, and increased PGD risk with cardiopulmonary bypass remains confounded by transfusions. Portable ex vivo lung perfusion (EVLP) may prevent PGD, but its use is limited to a handful of centers. Although updates to current PGD treatment are lacking, future therapies are promising with targeted therapy and the use of EVLP to pharmacologically recondition donor lungs. SUMMARY There is significant progress in defining PGD and identifying its several risk factors, but effective prevention and treatment strategies are needed.
Collapse
|
25
|
Natalini JG, Diamond JM. Primary Graft Dysfunction. Semin Respir Crit Care Med 2021; 42:368-379. [PMID: 34030200 DOI: 10.1055/s-0041-1728794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Primary graft dysfunction (PGD) is a form of acute lung injury after transplantation characterized by hypoxemia and the development of alveolar infiltrates on chest radiograph that occurs within 72 hours of reperfusion. PGD is among the most common early complications following lung transplantation and significantly contributes to increased short-term morbidity and mortality. In addition, severe PGD has been associated with higher 90-day and 1-year mortality rates compared with absent or less severe PGD and is a significant risk factor for the subsequent development of chronic lung allograft dysfunction. The International Society for Heart and Lung Transplantation released updated consensus guidelines in 2017, defining grade 3 PGD, the most severe form, by the presence of alveolar infiltrates and a ratio of PaO2:FiO2 less than 200. Multiple donor-related, recipient-related, and perioperative risk factors for PGD have been identified, many of which are potentially modifiable. Consistently identified risk factors include donor tobacco and alcohol use; increased recipient body mass index; recipient history of pulmonary hypertension, sarcoidosis, or pulmonary fibrosis; single lung transplantation; and use of cardiopulmonary bypass, among others. Several cellular pathways have been implicated in the pathogenesis of PGD, thus presenting several possible therapeutic targets for preventing and treating PGD. Notably, use of ex vivo lung perfusion (EVLP) has become more widespread and offers a potential platform to safely investigate novel PGD treatments while expanding the lung donor pool. Even in the presence of significantly prolonged ischemic times, EVLP has not been associated with an increased risk for PGD.
Collapse
Affiliation(s)
- Jake G Natalini
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
26
|
Prediction of donor related lung injury in clinical lung transplantation using a validated ex vivo lung perfusion inflammation score. J Heart Lung Transplant 2021; 40:687-695. [PMID: 33781664 DOI: 10.1016/j.healun.2021.03.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is an isolated organ assessment technique that has revolutionized the field of lung transplantation and enabled a safe increase in the number of organs transplanted. The objective of this study was to develop a protein-based assay that would provide a precision medicine approach to lung injury assessment during EVLP. METHODS Perfusate samples collected from clinical EVLP cases performed from 2009 to 2019 were separated into development (n = 281) and validation (n = 57) sets to derive and validate an inflammation score based on IL-6 and IL-8 protein levels in perfusate. The ability of an inflammation score to predict lungs suitable for transplantation and likely to produce excellent recipient outcomes (time on ventilator ≤ 3 days) was assessed. Inflammation scores were compared to conventional clinical EVLP assessment parameters and associated with outcomes, including primary graft dysfunction and patient care in the ICU. RESULTS An inflammation score accurately predicted the decision to transplant (AUROC 68% [95% CI 62-74]) at the end of EVLP and those transplants associated with short ventilator times (AUROC 73% [95% CI 66-80]). The score identified lungs more likely to develop primary graft dysfunction at 72-hours post-transplant (OR 4.0, p = 0.03). A model comprised of the inflammation score and ∆PO2 was able to determine EVLP transplants that were likely to have excellent recipient outcomes, with an accuracy of 87% [95% CI 83-92]. CONCLUSIONS The adoption of an inflammation score will improve accuracy of EVLP decision-making and increase confidence of surgical teams to determine lungs that are suitable for transplantation, thereby improving organ utilization rates and patient outcomes.
Collapse
|
27
|
Labarinas S, Coss-Bu JA, Onyearugbulem C, Heinle JS, Mallory GB, Gazzaneo MC. Influence of early extubation on post-operative outcomes after pediatric lung transplantation. Pediatr Transplant 2021; 25:e13776. [PMID: 32780552 DOI: 10.1111/petr.13776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 05/26/2020] [Accepted: 06/02/2020] [Indexed: 11/27/2022]
Abstract
Lung transplantation has become an accepted therapeutic option for a select group of children with end-stage lung disease. We evaluated the impact of early extubation in a pediatric lung transplant population and its post-operative outcomes. Single-center retrospective study. PICU within a tertiary academic pediatric hospital. Patients <22 years after pulmonary transplant between January 2011 and December 2016. A total of 74 patients underwent lung transplantation. The primary pretransplantation diagnoses included cystic fibrosis (58%), pulmonary fibrosis (9%), and surfactant dysfunction disorders (10%). Of 60 patients, 36 (60%) were extubated within 24 hours and 24 patients after 24 hours (40%). A total of seven patients (11.6%) required reintubation within 24 hours. Median length of stay for the early extubation group was shorter at 3 days ([(IQR) 2.2-4.7]) compared to 5 days (IQR, 3-7) (P = .02) in the late extubation group. Median costs were lower for the early extubation group with 13,833 US dollars (IQR, 9980-22,822) vs 23 671 US dollars (IQR, 16 673-39 267) (P = .043). Fourteen patients were in the PICU prior to their transplantation; this did not affect their early extubation success. Neither did the fact of requiring invasive or non-invasive mechanical ventilation before transplantation. Early extubation appears to be safe in a pediatric population after lung transplantation and is associated with a shorter LOS and decreased hospital costs. It may prevent known complications associated with mechanical ventilation.
Collapse
Affiliation(s)
- Sonia Labarinas
- Section of Critical Care Medicine, Department of Pediatrics, The University of Texas Health Science Center, Houston, TX, USA
| | - Jorge A Coss-Bu
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Chinyere Onyearugbulem
- Section of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Edinburg, TX, USA
| | - Jeffery S Heinle
- Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine, TX, USA
| | - George B Mallory
- Section of Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Maria C Gazzaneo
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Section of Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
28
|
Kolaitis NA, Gao Y, Soong A, Greenland JR, Hays SR, Golden J, Leard LE, Shah RJ, Kleinhenz ME, Katz PP, Venado A, Kukreja J, Blanc PD, Singer JP. Primary graft dysfunction attenuates improvements in health-related quality of life after lung transplantation, but not disability or depression. Am J Transplant 2021; 21:815-824. [PMID: 32794295 DOI: 10.1111/ajt.16257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/17/2020] [Accepted: 07/31/2020] [Indexed: 01/25/2023]
Abstract
Disability, depressive symptoms, and impaired health-related quality of life (HRQL) are common among patients with life-threatening respiratory compromise. We sought to determine if primary graft dysfunction (PGD), a syndrome of acute lung injury, attenuates improvements in patient-reported outcomes after transplantation. In a single-center prospective cohort, we assessed disability, depressive symptoms, and HRQL before and at 3- to 6-month intervals after lung transplantation. We estimated the magnitude of change in disability, depressive symptoms, and HRQL with hierarchical segmented linear mixed-effects models. Among 251 lung transplant recipients, 50 developed PGD Grade 3. Regardless of PGD severity, participants had improvements in disability and depressive symptoms, as well as generic-physical, generic-mental, respiratory-specific, and health-utility HRQL, exceeding 1- to 4-fold the minimally clinically important difference across all instruments. Participants with PGD Grade 3 had a lower magnitude of improvement in generic-physical HRQL and health-utility than in all other participants. Among participants with PGD Grade 3, prolonged mechanical ventilation was associated with greater attenuation of improvements. PGD remains a threat to the 2 primary aims of lung transplantation, extending survival and improving HRQL. Attenuation of improvement persists long after hospital discharge. Future studies should assess if interventions can mitigate the impact of PGD on patient-reported outcomes.
Collapse
Affiliation(s)
- Nicholas A Kolaitis
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Ying Gao
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Allison Soong
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - John R Greenland
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Steven R Hays
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Jeffrey Golden
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Lorriana E Leard
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Rupal J Shah
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Mary Ellen Kleinhenz
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Patricia P Katz
- Division of Rheumatology, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Aida Venado
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Jasleen Kukreja
- Division of Thoracic Surgery, Department of Surgery, School of Medicine, University of California, San Francisco, California, USA
| | - Paul D Blanc
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Jonathan P Singer
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, California, USA
| |
Collapse
|
29
|
Natalini JG, Diamond JM, Porteous MK, Lederer DJ, Wille KM, Weinacker AB, Orens JB, Shah PD, Lama VN, McDyer JF, Snyder LD, Hage CA, Singer JP, Ware LB, Cantu E, Oyster M, Kalman L, Christie JD, Kawut SM, Bernstein EJ. Risk of primary graft dysfunction following lung transplantation in selected adults with connective tissue disease-associated interstitial lung disease. J Heart Lung Transplant 2021; 40:351-358. [PMID: 33637413 DOI: 10.1016/j.healun.2021.01.1391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/23/2020] [Accepted: 01/19/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Previous studies have reported similarities in long-term outcomes following lung transplantation for connective tissue disease-associated interstitial lung disease (CTD-ILD) and idiopathic pulmonary fibrosis (IPF). However, it is unknown whether CTD-ILD patients are at increased risk of primary graft dysfunction (PGD), delays in extubation, or longer index hospitalizations following transplant compared to IPF patients. METHODS We performed a multicenter retrospective cohort study of CTD-ILD and IPF patients enrolled in the Lung Transplant Outcomes Group registry who underwent lung transplantation between 2012 and 2018. We utilized mixed effects logistic regression and stratified Cox proportional hazards regression to determine whether CTD-ILD was independently associated with increased risk for grade 3 PGD or delays in post-transplant extubation and hospital discharge compared to IPF. RESULTS A total of 32.7% (33/101) of patients with CTD-ILD and 28.9% (145/501) of patients with IPF developed grade 3 PGD 48-72 hours after transplant. There were no significant differences in odds of grade 3 PGD among patients with CTD-ILD compared to those with IPF (adjusted OR 1.12, 95% CI 0.64-1.97, p = 0.69), nor was CTD-ILD independently associated with a longer post-transplant time to extubation (adjusted HR for first extubation 0.87, 95% CI 0.66-1.13, p = 0.30). However, CTD-ILD was independently associated with a longer post-transplant hospital length of stay (median 23 days [IQR 14-35 days] vs17 days [IQR 12-28 days], adjusted HR for hospital discharge 0.68, 95% CI 0.51-0.90, p = 0.008). CONCLUSION Patients with CTD-ILD experienced significantly longer postoperative hospitalizations compared to IPF patients without an increased risk of grade 3 PGD.
Collapse
Affiliation(s)
- Jake G Natalini
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary K Porteous
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Ann B Weinacker
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Laurie D Snyder
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Chadi A Hage
- Division of Pulmonary Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P Singer
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Edward Cantu
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elana J Bernstein
- Division of Rheumatology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York.
| |
Collapse
|
30
|
Schwarz S, Benazzo A, Dunkler D, Muckenhuber M, Sorbo LD, Di Nardo M, Sinn K, Moser B, Matilla JR, Lang G, Taghavi S, Vamos FR, Jaksch P, Cypel M, Keshavjee S, Klepetko W, Hoetzenecker K. Ventilation parameters and early graft function in double lung transplantation. J Heart Lung Transplant 2020; 40:4-11. [PMID: 33144029 DOI: 10.1016/j.healun.2020.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/01/2020] [Accepted: 10/07/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Currently, the primary graft dysfunction (PGD) score is used to measure allograft function in the early post-lung transplant period. Although PGD grades at later time points (T48 hours and T72 hours) are useful to predict mid- and long-term outcomes, their predictive value is less relevant within the first 24 hours after transplantation. This study aimed to evaluate the capability of PGD grades to predict prolonged mechanical ventilation (MV) and compare it with a model derived from ventilation parameters measured on arrival at the intensive care unit (ICU). METHODS A retrospective single-center analysis of 422 double lung transplantations (LTxs) was performed. PGD was assessed 2 hours after arrival at ICU, and grades were associated with length of MV (LMV). In addition, peak inspiratory pressure (PIP), ratio of the arterial partial pressure of oxygen to fraction of inspired oxygen (P/F ratio), and dynamic compliance (cDyn) were collected, and a logistic regression model was created. The predictive capability for prolonged MV was calculated for both (the PGD score and the model). In a second step, the created model was externally validated using a prospective, international multicenter cohort including 102 patients from the lung transplant centers of Vienna, Toronto, and Budapest. RESULTS In the retrospective cohort, a high percentage of extubated patients was reported at 24 hours (35.1%), 48 hours (68.0%), and 72 hours (80.3%) after transplantation. At T0 (time point defined as 2 hours after arrival at the ICU), patients with PGD grade 0 had a shorter LMV with a median of 26 hours (interquartile range [IQR]: 16-47 hours) than those with PGD grade 1 (median: 42 hours, IQR: 27-50 hours), PGD grade 2 (median: 37.5 hours, IQR: 15.5-78.5 hours), and PGD grade 3 (median: 46 hours, IQR: 27-86 hours). However, IQRs largely overlapped for all grades, and the value of PGD to predict prolonged MV was poor. A total of 3 ventilation parameters (PIP, cDyn, and P/F ratio), determined at T0, were chosen on the basis of clinical reasoning. A logistic regression model including these parameters predicted prolonged MV (>72 hours) with an optimism-corrected area under the curve (AUC) of 0.727. In the prospective validation cohort, the model proved to be stable and achieved an AUC of 0.679. CONCLUSIONS The prediction model reported in this study combines 3 easily obtainable variables. It can be employed immediately after LTx to quantify the risk of prolonged MV, an important early outcome parameter.
Collapse
Affiliation(s)
- Stefan Schwarz
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Alberto Benazzo
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniela Dunkler
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Moritz Muckenhuber
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Lorenzo Del Sorbo
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Matteo Di Nardo
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Katharina Sinn
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Bernhard Moser
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - José Ramon Matilla
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Gyoergy Lang
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Shahrokh Taghavi
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Ferenc Renyi Vamos
- Department of Thoracic Surgery, Semmelweis University-National Institute of Oncology, Budapest, Hungary
| | - Peter Jaksch
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Marcelo Cypel
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Walter Klepetko
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
31
|
Kulkarni HS, Ramphal K, Ma L, Brown M, Oyster M, Speckhart KN, Takahashi T, Byers DE, Porteous MK, Kalman L, Hachem RR, Rushefski M, McPhatter J, Cano M, Kreisel D, Scavuzzo M, Mittler B, Cantu E, Pilely K, Garred P, Christie JD, Atkinson JP, Gelman AE, Diamond JM. Local complement activation is associated with primary graft dysfunction after lung transplantation. JCI Insight 2020; 5:138358. [PMID: 32750037 PMCID: PMC7526453 DOI: 10.1172/jci.insight.138358] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/29/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The complement system plays a key role in host defense but is activated by ischemia/reperfusion injury (IRI). Primary graft dysfunction (PGD) is a form of acute lung injury occurring predominantly due to IRI, which worsens survival after lung transplantation (LTx). Local complement activation is associated with acute lung injury, but whether it is more reflective of allograft injury compared with systemic activation remains unclear. We proposed that local complement activation would help identify those who develop PGD after LTx. We also aimed to identify which complement activation pathways are associated with PGD. METHODS We performed a multicenter cohort study at the University of Pennsylvania and Washington University School of Medicine. Bronchoalveolar lavage (BAL) and plasma specimens were obtained from recipients within 24 hours after LTx. PGD was scored based on the consensus definition. Complement activation products and components of each arm of the complement cascade were measured using ELISA. RESULTS In both cohorts, sC4d and sC5b-9 levels were increased in BAL of subjects with PGD compared with those without PGD. Subjects with PGD also had higher C1q, C2, C4, and C4b, compared with subjects without PGD, suggesting classical and lectin pathway involvement. Ba levels were higher in subjects with PGD, suggesting alternative pathway activation. Among lectin pathway–specific components, MBL and FCN-3 had a moderate-to-strong correlation with the terminal complement complex in the BAL but not in the plasma. CONCLUSION Complement activation fragments are detected in the BAL within 24 hours after LTx. Components of all 3 pathways are locally increased in subjects with PGD. Our findings create a precedent for investigating complement-targeted therapeutics to mitigate PGD. FUNDING This research was supported by the NIH, American Lung Association, Children’s Discovery Institute, Robert Wood Johnson Foundation, Cystic Fibrosis Foundation, Barnes-Jewish Hospital Foundation, Danish Heart Foundation, Danish Research Foundation of Independent Research, Svend Andersen Research Foundation, and Novo Nordisk Research Foundation. Substantial differences between local and systemic complement activation in lung transplant recipients who develop primary graft dysfunction are identified in two independent cohorts.
Collapse
Affiliation(s)
- Hrishikesh S Kulkarni
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kristy Ramphal
- Department of Medicine, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lina Ma
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Melanie Brown
- Department of Medicine, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle Oyster
- Department of Medicine, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kaitlyn N Speckhart
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Tsuyoshi Takahashi
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Derek E Byers
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Mary K Porteous
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Laurel Kalman
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ramsey R Hachem
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Melanie Rushefski
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ja'Nia McPhatter
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marlene Cano
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Brigitte Mittler
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Edward Cantu
- Department of Surgery, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katrine Pilely
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Section 7631, Rigshospitalet and Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Peter Garred
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Section 7631, Rigshospitalet and Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Jason D Christie
- Department of Medicine, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John P Atkinson
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Andrew E Gelman
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joshua M Diamond
- Department of Medicine, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
32
|
Lung Transplantation for Cystic Fibrosis. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
33
|
Anderson MR, Udupa JK, Edwin E, Diamond JM, Singer JP, Kukreja J, Hays SR, Greenland JR, Ferrante A, Lippel M, Blue T, McBurnie A, Oyster M, Kalman L, Rushefski M, Wu C, Pednekar G, Liu W, Arcasoy S, Sonett J, D'Ovidio F, Bacchetta M, Newell JD, Torigian D, Cantu E, Farber DL, Giles JT, Tong Y, Palmer S, Ware LB, Hancock WW, Christie JD, Lederer DJ. Adipose tissue quantification and primary graft dysfunction after lung transplantation: The Lung Transplant Body Composition study. J Heart Lung Transplant 2019; 38:1246-1256. [PMID: 31474492 PMCID: PMC6883162 DOI: 10.1016/j.healun.2019.08.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 07/30/2019] [Accepted: 08/05/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Obesity is associated with an increased risk of primary graft dysfunction (PGD) after lung transplantation. The contribution of specific adipose tissue depots is unknown. METHODS We performed a prospective cohort study of adult lung transplant recipients at 4 U.S. transplant centers. We measured cross-sectional areas of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) on chest and abdominal computed tomography (CT) scans and indexed each measurement to height.2 We used logistic regression to examine the associations of adipose indices and adipose classes with grade 3 PGD at 48 or 72 hours, and Cox proportional hazards models to examine survival. We used latent class analyses to identify the patterns of adipose distribution. We examined the associations of adipose indices with plasma biomarkers of obesity and PGD. RESULTS A total of 262 and 117 subjects had available chest CT scans and underwent protocol abdominal CT scans, respectively. In the adjusted models, a greater abdominal SAT index was associated with an increased risk of PGD (odds ratio 1.9, 95% CI 1.02-3.4, p = 0.04) but not with survival time. VAT indices were not associated with PGD risk or survival time. A greater abdominal SAT index correlated with greater pre- and post-transplant leptin (r = 0.61, p < 0.001, and r = 0.44, p < 0.001), pre-transplant IL-1RA (r = 0.25, p = 0.04), and post-transplant ICAM-1 (r = 0.25, p = 0.04). We identified 3 latent patterns of adiposity. The class defined by high thoracic and abdominal SAT had the greatest risk of PGD. CONCLUSIONS Subcutaneous, but not visceral, adiposity is associated with an increased risk of PGD after lung transplantation.
Collapse
Affiliation(s)
- Michaela R Anderson
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jayaram K Udupa
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ethan Edwin
- Columbia Institute of Human Nutrition, Columbia University Medical Center, New York, New York
| | - Joshua M Diamond
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan P Singer
- Department of Medicine University of California at San Francisco, San Francisco, California
| | - Jasleen Kukreja
- Department of Surgery, University of California at San Francisco, San Francisco, California
| | - Steven R Hays
- Department of Medicine University of California at San Francisco, San Francisco, California
| | - John R Greenland
- Department of Medicine University of California at San Francisco, San Francisco, California
| | - Anthony Ferrante
- Columbia Institute of Human Nutrition, Columbia University Medical Center, New York, New York
| | - Matthew Lippel
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Tatiana Blue
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Amika McBurnie
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Michelle Oyster
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Kalman
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melanie Rushefski
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caiyun Wu
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gargi Pednekar
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wen Liu
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Selim Arcasoy
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Joshua Sonett
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Frank D'Ovidio
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John D Newell
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Drew Torigian
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna L Farber
- Department of Surgery, University of California at San Francisco, San Francisco, California; Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York; Department of Microbiology and Immunology, Columbia University Medical Center, New York, New York
| | - Jon T Giles
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yubing Tong
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott Palmer
- Department of Medicine, Duke University & Duke Clinical Research Institute, Durham, North Carolina
| | - Lorraine B Ware
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wayne W Hancock
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Lederer
- Department of Medicine, Columbia University Medical Center, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, New York.
| |
Collapse
|
34
|
Katsis J, Garrity E. The Use of Gene Expression Profiling in Lung Transplantation. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00253-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
35
|
Commentary: Central defense on trial. J Thorac Cardiovasc Surg 2019; 160:331-332. [PMID: 31672391 DOI: 10.1016/j.jtcvs.2019.09.124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 09/27/2019] [Accepted: 09/29/2019] [Indexed: 11/23/2022]
|
36
|
Lung Transplantation for Idiopathic Pulmonary Fibrosis. Respir Med 2019. [DOI: 10.1007/978-3-319-99975-3_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
37
|
Rosenheck J, Pietras C, Cantu E. Early Graft Dysfunction after Lung Transplantation. CURRENT PULMONOLOGY REPORTS 2018; 7:176-187. [PMID: 31548919 PMCID: PMC6756771 DOI: 10.1007/s13665-018-0213-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Primary graft dysfunction is an acute lung injury syndrome occurring immediately following lung transplantation. This review aims to provide an overview of the current understanding of PGD, including epidemiology, immunology, clinical outcomes and management. RECENT FINDINGS Identification of donor and recipient factors allowing accurate prediction of PGD has been actively pursued. Improved understanding of the immunology underlying PGD has spurred interest in identifying relevant biomarkers. Work in PGD prediction, severity stratification and targeted therapies continue to make progress. Donor expansion strategies continue to be pursued with ex vivo lung perfusion playing a prominent role. While care of PGD remains supportive, ECMO has established a prominent role in the early aggressive management of severe PGD. SUMMARY A consensus definition of PGD has allowed marked advances in research and clinical care of affected patients. Future research will lead to reliable predictive tools, and targeted therapeutics of this important syndrome.
Collapse
Affiliation(s)
- Justin Rosenheck
- Pulmonary, Allergy, and Critical Care Division, University
of Pennsylvania Perelman School of Medicine
| | - Colleen Pietras
- Department of Surgery, University of Pennsylvania Perelman
School of Medicine
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania Perelman
School of Medicine
| |
Collapse
|
38
|
Abstract
Lung transplantation can improve quality of life and prolong survival for individuals with end-stage lung disease, and many advances in the realms of both basic science and clinical research aspects of lung transplantation have emerged over the past few decades. However, many challenges must yet be overcome to increase post-transplant survival. These include successfully bridging patients to transplant, expanding the lung donor pool, inducing tolerance, and preventing a myriad of post-transplant complications that include primary graft dysfunction, forms of cellular and antibody-mediated rejection, chronic lung allograft dysfunction, and infections. The goal of this manuscript is to review salient recent and evolving advances in the field of lung transplantation.
Collapse
Affiliation(s)
- Keith C Meyer
- UW Lung Transplant & Advanced Pulmonary Disease Program, Section of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
39
|
Onyearugbulem C, Williams L, Zhu H, Gazzaneo MC, Melicoff E, Das S, Coss-Bu J, Lam F, Mallory G, Munoz FM. Risk factors for infection after pediatric lung transplantation. Transpl Infect Dis 2018; 20:e13000. [PMID: 30221817 DOI: 10.1111/tid.13000] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 07/19/2018] [Accepted: 08/20/2018] [Indexed: 12/28/2022]
Abstract
Although infection is the leading cause of death in the first year following pediatric lung transplantation, there are limited data on risk factors for early infection. Sepsis remains under-recognized and under-reported in the early post-operative period for lung transplant recipients (LTR). We evaluated the incidence of infection and sepsis, and identified risk factors for infection in the early post-operative period in pediatric LTRs. A retrospective review of medical records of LTRs at a large quaternary-care hospital from January 2009 to March 2016 was conducted. Microbiology results on days 0-7 after transplant were obtained. Sepsis was defined using the 2005 International Pediatric Consensus Conferencecriteria. Risk factors included history of recipient and donor infection, history of multi-drug resistant (MDR) infection, nutritional status, and surgical times. Among the 98 LTRs, there were 22 (22%) with post-operative infection. Prolonged donor ischemic time ≥7 hours, cardiopulmonary bypass(CPB) time ≥340 minutes, history of MDR infection and diagnosis of cystic fibrosis were significantly associated with infection. With multivariable regression analysis, only prolonged donor ischemic time remained significant (OR 4.4, 95% CI: 1.34-14.48). Further research is needed to determine whether processes to reduce donor ischemic time could result in decreased post-transplant morbidity.
Collapse
Affiliation(s)
- Chinyere Onyearugbulem
- Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Critical Care Medicine, Texas Children's Hospital, Houston, Texas
| | - Lauren Williams
- Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Huirong Zhu
- Texas Children's Hospital, Houston, Texas.,Outcome and Impact Service, Texas Children's Hospital, Houston, Texas
| | - Maria C Gazzaneo
- Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Critical Care Medicine, Texas Children's Hospital, Houston, Texas.,Section of Pulmonary Medicine and Lung Transplant, Texas Children's Hospital, Houston, Texas
| | - Ernestina Melicoff
- Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Pulmonary Medicine and Lung Transplant, Texas Children's Hospital, Houston, Texas
| | - Shailendra Das
- Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Pulmonary Medicine and Lung Transplant, Texas Children's Hospital, Houston, Texas
| | - Jorge Coss-Bu
- Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Critical Care Medicine, Texas Children's Hospital, Houston, Texas
| | - Fong Lam
- Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Critical Care Medicine, Texas Children's Hospital, Houston, Texas
| | - George Mallory
- Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Pulmonary Medicine and Lung Transplant, Texas Children's Hospital, Houston, Texas
| | - Flor M Munoz
- Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Infectious Diseases and Transplant, Texas Children's Hospital, Houston, Texas
| |
Collapse
|
40
|
Advances in ex-vivo donor lung organ care. THE LANCET RESPIRATORY MEDICINE 2018; 6:319-320. [PMID: 29650409 DOI: 10.1016/s2213-2600(18)30144-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 03/23/2018] [Indexed: 11/22/2022]
|